False Claims Act dangers lurk beyond Medicare Advantage Risk Adjustment

Lexology January 31, 2023
Reed Smith LLP

The federal False Claims Act (FCA) has long been a threat to Medicare Advantage organizations (MAOs) and Medicaid managed care organizations (Medicaid MCOs) due to the nature of the business. Historically, however, health plans were not primary targets as the government and relators’ counsel focused on providers. Medicare Advantage Risk Adjustment (MA RA) shifted that landscape, with Department of Justice (DOJ) and whistleblowers bringing numerous cases against MAOs for the alleged submission of false MA RA data. While those MA RA cases create significant risk, they are just the tip of the iceberg as the government and relators’ counsel now have plans directly in their crosshairs. Other emerging areas of FCA risk include:

• Federal Anti-Kickback Statute (AKS). The AKS...

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